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HomeMy WebLinkAboutSeptic Pumping Slip - 314 REA STREET 4/6/2016 s Commonwealth of Massachusetts it City/Town of r - System m i n cord NORTH ANDOVER Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CIVIR 15.351. A. Facility information Important: When filling out 1. System Location: forms on the computer,used only the tab key Address to move your cursor-do not City/Tom Slate Zip Code use the return key, 2. System Owner: r - Name �° Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date )` -- 2. Quantity Pumped: Gallons 3. Type of system. ❑ Cesspool(s) ❑°Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes E�_Ko If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Vehicle License Number Gompany 7. Location where contents were disposed: Signature of Hauler t'. 'ate Signature of Receiving Facility dff1, e I5form4,doc•03/06 System Pumping Record•Page t of i Ccrnrnonwealth of Masseichusetts �r r N I I Town of ' r, l e'l vr< ystern Pumping Record Form 4 information has provided this form font the sameias thatsprovided here. Before using his form,but heck with your infortrlatian must be substantially local Board of Health to determine the norm they use The System days pumping ing e Record most lobe isubmitted to the local Board of Health or other approving authority accordance with 310 CMR 15.351. A. Facility Information 1 System Location: Address .Ziplp Code �.. - Slate Ciiyfrown 2 System owner > Name Address(If different from localion) Sta.t_. . . -i_--.d.�_...—} _ zip Cade Tefeohone Number B. Pumping Record .._ _...._.. __.-- 1 late of Pumping pate 2 Quantity Pumped: Gailons 3 Type of system: ❑ Cesspool(s) 1g, Septic Tank ❑ Tight Tank ❑ Grease Tray 0 Other(describe) — -- -- _. 4. Effluent Tee Filter present? Yes ❑ No If yes, was It cleaned?(:01 ° Yes j No 5. Condition of Syste ----- �1' 6. System Pumped B : 9, Vehicle license umber — -- — Name Wirid River vi n to Company 7. Location where conten sere disposed . f7 Signature of Hauler pate Srgnalure of Receiving Facility syslen;Pump og Record•"age I of i5form4.doc-03106 Commonwealth of Massachusetts City/Town of THANDOVER Pumping System r Form 4 DEP has provided this form for use by local Boards of Health. Other forms may w used, but the information must be substantially the same as that provided here. Before using this form,Check with your local Board of Health to determine the form they use.The System Pumping Reword must be submitted to the local Board of Health or other approving authority within 14 days fr h ,° le' " t m, accordance with 310 GMR 15.351. A. Facility information f �4 Impolunt: �r)� i4°ff r�li 1ti✓I„i'LL when filling out 1• SysteYr J►/L�o tion: � Forms on the ,1,. 1 computer.use / arty the tab key Address j to move your o Cursor-do not — ---�” State .. Zip Code use the return CilyCrrnwn key. 2, System Owner: Name Addrese(If different from location). __......_.�., .._. �, ,_®. _.. .._ Cilyt'rown . _._�, . . .,� ._. ..,.., --• State .. _... �IpC�e- Tele•pnone Number P Pumping Record 1. Date of Pumping Ea-16 2. Quantity Pumped: Gallons 3. Type of system: Cesspool(s) pti+C Tank. El Tight Tank Grease Trap ❑ other(describe). _. _.. _._ ..... . 4. Effluent Tee Filter present? es ❑ No if yes, was it cleaned? es ❑ No 5. Condition of System: 6. System Pumped By; _ ��-- - -• V4YtICfe License um qr r Cortmpany 7. Location where contents were disposed: . : Signature of Hauler Crate _ - .� Signature of Raceiving Facility Crate t5icrm4.dac D3lOB Systiern Pumping ReC61d•Page I of f Commonwealth of Massachusetts Esimmaigm City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the Information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. Syst m Location: forms on the computer, use O only the tab key Address � " to move your C�(��—v l cursor-do not Cit frown State Code use the return y Zip key. 2. System Owner: Name Address(if different from location) CItyrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2- Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes �o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Sys Pumped Q Name Vehicle License Number Company 7. location where contents were disposed: Sign r au Date t5form4.doc-06103 System Pumping Record•Page 1 of 1 v r{ (b� pI]U,�'yy`\J�'a'�r:ylf+'n�v5r °"x',,""11 'S,'. '%}. o��f";.,•rr;71 CH U e �Wfh,4,!" �,������, •,��j �p'p �p..�{- p� �� r P ,♦ r',J11"I�ill.l;�,: 0Wt{ )11:�/•1'�'�,��J'I i!"'1�11r,A(• .i{14), rn r9V) Y'Ir ,., ''),If.,t;l,,),y;�,,,• �u,l,1q'�jr WP<r"'i r , , � 1`�kI/"� •,hay pro,vld©d � (orm Car us0 by 10061 �w fik ���i bp�5y$Gsm PumPln score by submlktvd to thv,locul'6oArc1 of Health or other approving aDin, r, FaClllty. Inf6r tlon r t n�Q r{8llt ,' ,l• uj Y.YW M? v ouI 1 ; System Loca�on ,`''C�1npUtbJ� 1•'�Y,. oNytha tab k4y LO move yow Cur ua+'tha'rolum;,Y� .;.,i:; „Clfyrirwn "' Slel r 'Y'/' Ott n 1'4i 'b;''''"'1.1i�,,)i,,ri: '•i'i/4 r.yf�'a'1,ii ., r W VWO P x'r,r''yl rf y i7'W1,4,1,`yfx4•})•,i.2 'f SY8 Orn ® r•'vI I,/''1 . 1 �I ,"t1"fi r • �{':4z' �;�)G ,ly"tilv4rl:�7i'"(,.�`wt,Y N�I)l;f;•iY,1, iwnVV�'I�r1l �.i.f, 'Y•.�J•ti J�': „{ S 'r,iV� ,,, r 1 1 ,,. ;�ittit:�'.: a.':j.;NaRlf fn',r 1 �'•(1 rRr, 'w.�l.,., '1' .f, ti,l 'I rh1: �!r,6q,o.r+,Y'�,;/vtiJ::+•�' 'I , Ad)draaa(II dUf®r®nl rpm I4caU0n) QW zip cwO 1'• Tolaphono Nvmbor tr/" ffi' �5",11'x•" ••"• 3 ! , rw �r� Ump�11 � �t'dl ' r I,r y r .. �jl•J1 ' Giiifylrl,r I �,.'JI,`Iir>f.A'jI,',.� �1i .1 «� 1 Da,W of Pumpinq`',r { C�alo 2, C1uantJty Pumped: 43r•' �rYp,�,a('bY3lel71;";;,'� Cesspool($) �epllc Tank Tlght Tank ;'r '•ir:,r"' '�+"!t�F,1h,!;54y�,'i�lyiilyr},4f'r.,1 .I r%+' ''..�� }Mr Effl�erit Tea Pllte 1 r v v !4" i1J,1}t1yy1 i , i r,IV' C �s 1n' 'Yes No' Ir y0$I wa$ II cl®anod? 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System Owner: Semi"e Address(if different from—location) —------ —----- City/Town State Zip Code MAY Telephone Number B. P u m pi n g Recbfd- 1. Date of Pumping 2. Quantity Pumped: Dat Gallons Type of system: ❑ Cesspool(s) l 'Septic Tank ❑ Tight Tank ❑ Other(describe),, 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes Q--N10 5. Condition of System: — -- 6. System Pumped By: hicle License Number 7. Location where contents were disposed: e, e, ignatureofr 9 ler Date http://www.mass,g v/dep @'er'approvals/t5forms.htm*inspect t5form4.doc•06/03 System Pumping Record-Page 1 of 1 �. r,...,,.... TOWN OF NORTH ANDOVE,'k / SYSTEM PUMPING C.C7RI) SYSTEM rJWN R ArJ[JR SS SYSTEM L.OGAInION DATE OF PU gyp. ,. UANTiT �� .�.,_� ..a.. Q Y PlJMA6®� . S00C Tahk; NO YSS i NA rURU as sBRVICE: ROU'rINE... OUS V R A'rlC>td9; ND"rl" FUU, TYJ COVER �tOV0a, HEAVY ORWB SAPYLEs IN P'L,AC L OXCU$SIYB SOLIDS-­­ FLOODED� C) itUN�AC`K LID CA YOYEK OTHER EXPLAIN ,��.,,, `..,. r.`2�, VUMMENTS, `'UN I"LIV'I'S rKANsp6,KK 3U I'U